[DRAFT NOTIFICATION FORM – MUST BE CUSTOMIZED WITH HOSPITALSPECIFIC DISCLOSURES.]
NOTICE TO PATIENTS
As a prospective patient of [Hospital Name], we are pleased to inform you of the
following:
DISCLOSURE OF PHYSICIAN OWNERSHIP
1.
[Hospital Name] (the “Hospital”) is [partly/fully] owned by physicians and meets
the federal definition of a physician owned hospital as specified in 42 CFR 489.3.
A list of the Hospital’s physician owners is available upon request.
2.
You have the right to choose the provider of your health care services.
Therefore, you have the option to use a health care facility other than [Hospital
Name].
3.
You will not be treated differently by your physician if you choose to use a
different facility. If desired, your physician can provide information about
alternative providers.
DISCLOSURE OF EMERGENCY RESPONSE PLAN [REQUIRED ONLY IF
HOSPITAL WILL NOT HAVE A PHYSICIAN PRESENT ON-SITE 24 HOURS A
DAY, 7 DAYS A WEEK.]
1.
[Hospital Name] has arranged for one or more physicians to be on-site at the
Hospital and available to respond to medical emergencies during
[most/substantially all/daytime – select appropriate term] hours of operation.
However, we cannot guarantee that a physician will be present at the Hospital at
all times. The Hospital has taken certain measures to ensure that qualified and
properly trained medical personnel are available to respond to any medical
emergency that may arise when a physician is not present at the Hospital.
2.
[Describe how the hospital will meet the medical needs of any patient who
develops an emergency medical condition at a time when no physician is
present in the hospital. For example:
 Will the hospital transfer the patient to another nearby facility that is
staffed with on-site physicians 24 hours a day, 7 days a week? If so,
does the hospital have a transfer agreement in place? What
arrangements are in place for transporting the patient?
 Will the hospital communicate with emergency personnel/ambulance
service to obtain a transfer in case of a patient emergency? If so,
through what mechanism?
 Does the hospital have a physician on-call and/or non-physician
medical personnel on-site to respond to emergencies when a
physician is not on-site? If so, within what period of time is an oncall physician required to respond to any such medical emergency?
[DRAFT NOTIFICATION FORM – MUST BE CUSTOMIZED WITH HOSPITALSPECIFIC DISCLOSURES.]


Does the hospital have an emergency department, intensive care
unit, or other inpatient unit capable of handling medical emergencies
that is staffed around the clock by qualified personnel?
Is the hospital able to provide resuscitation and other basic lifesaving measures at all times?]
[Note: do not overstate capabilities for responding to medical emergencies.
Consider adding in qualifying language to appropriately disclose the
hospital’s capabilities and limitations.]
3. If you would like additional information about [Hospital Name]’s capabilities for
handling medical emergencies please contact ______________ at
______________.
If you have any questions regarding the information contained in this Notice to
Patients, please feel free to ask your physician or a representative of [Hospital
Name]. We welcome you as a patient and value our relationship with you.
Acknowledgment of Disclosure
By signing this Acknowledgment of Disclosure, you acknowledge that you have read
and understand the foregoing Notice to Patients regarding physician ownership and
patient safety measures.
__________________________ _________
Signature of Patient
____________________________________
Type or Print Name of Patient
___________________________________
Signature of Parent or Guardian (if applicable)
____________________________________
Type or Print Name of Parent or Guardian (if applicable)
Date: ______________________________